Summary Whilst en route to Montreal, from St. John's, Newfoundland, the wheelsman of the watch was struck in the head by the 10 cm quick connect cap from the Flume tank filling line when he attempted to remove the cap while the line was pressurized. The vessel returned to St.John's, to land the injured wheelsman. Ce rapport est galement disponible en franais. Other Factual Information The MV CICERO is a steel-hulled vessel arranged with the accommodation forward. A container deck extends aft from the accommodation, below which are the ro-ro decks. The machinery space is midships, below the main ro-ro deck. Valid certificates for the vessel and the nature of the voyage undertaken were on board the vessel. The officers held valid certificates of competency for the positions they occupied and for the intended voyage. The vessel is fitted with a Flume Stabilization System, which provides roll stabilization. The Flume tank is fitted between frames 124 and 131 above the container deck, aft of the accommodation. Sea water is supplied to the Flume tank from the general service pump in the engine-room through a non-return valve at the pump, then via a 10cm pipe fitted with a butterfly valve in the engine-room. To prevent accidental filling of the Flume tank, the 10cm pipe was fitted with a male quick connect coupling and a cap, made of brass, weighing approximately 0.9kg. A 10cm flexible hose is used to join the fixed supply pipe to the fixed supply pipe that runs up the forward face of, and into, the Flume tank. When filling the Flume tank, the cap is removed from the pipe and a 10cm hose with a female quick connect coupling is connected. The hose section in the filling system had reportedly been installed approximately two years prior to the occurrence, as there was concern that there could be accidental filling of the Flume tank via fixed pipe and hose. When not in use the Flume tank is drained. The Flume tank is normally filled to the desired level prior to departure from port. Once filling is completed, the flexible hose is disconnected and the cap put in place. There is nothing at the deck level to indicate if the supply pipe is pressurized or if the Flume tanks contain water. History of the Voyage On the 22 May 1997 the CICERO was engaged in discharging and loading containers and ro-ro trailers for Montreal. During that time the Flume tank was empty. The chief officer ordered the Flume tank filling hose connected and made ready to fill the tank to its working level. The chief officer, prior to taking over his watch confirmed that, as ordered, the flexible hose in the Flume tank filling line had been connected. Following departure from St. John's, the chief officer again observed that the flexible filling hose was connected. Once the aft mooring lines had been secured, the second mate, with two wheelsmen and the deck cadet, proceeded to the midship area on the starboard side just aft of the Flume tank and secured the gangway for sea. The second mate then checked the Flume tank filling hose. Finding that it was connected, he felt it to ascertain whether or not water was flowing through it. He was satisfied that no water was flowing through the pipe. The second mate, who had neither received instructions from the chief mate nor consulted the posted operational instructions, believed that the Flume tank had been filled prior to departure, as was normally done. He directed one of the wheelsmen to disconnect the hose and install the cap. No report of this action was made to the officer of the watch. At 2254 the vessel departed St. John's bound for Montreal.[1] Once outside the narrows of St.John's, the master decided that about 100 tonnes of water would be required in the Flume tank to attenuate the roll of the vessel. The chief officer called the engineer on watch to start pumping water up to the Flume tank. After a short period, the engineer of the watch phoned the wheelhouse and stated to the chief officer that there was a problem, as the pressure on the discharge side of the pump was too high, at about 7 bar. Normal discharge pressure was 3-4 bar. The chief officer, who was now officer of the watch, sent the wheelsman down to check the Flume tank pipe connection. The wheelsman returned to the bridge and reported to the chief officer that the hose was not connected and that the supply pipe was capped. The chief officer called the engine-room and told the engineer of the watch to shut down the pump. He did not ask for the Flume tank supply line to be drained. The wheelsman was sent down to connect the hose. The chief officer cautioned him to ensure that the pressure in the line had dropped. At about 2325 the wheelsman undid the quick connect cap on the still-pressurized 10mm line and was struck on the head by the cap. The master, who was outside on the port side of the bridge deck heard a loud report from the vicinity of the Flume tank filling line. He immediately proceeded to the bridge, alerted the chief officer that the wheelsman may have been injured, took control of the vessel and sent the chief officer to check on the wheelsman. The chief officer found the wheelsman lying unconscious and bleeding on the deck near the Flume tank filling line. The flexible filling line was disconnected and the 10 cm quick connect cap was found off the pipe, hanging from its securing line. The chief officer went to the crew mess to get assistance. He retrieved the first aid kit and returned to the site of the accident with three crew members and a stretcher. First aid was administered to the wheelsman and he was removed by stretcher from the deck into the accommodation. At 2332 the master informed St. John's Coast Guard Radio that he was in approximate position 47 30.7' N, 052 35.3' W and had an emergency on board and requested an ambulance to be available when the vessel docked at Pier 5 in St. John's. On May 23, at 0028, the vessel arrived at Pier 5 and was met by the ambulance. The injured wheelsman was transported to the Health Science Centre in St. John's for treatment. Weather at the time of the occurrence was reported as clear with winds southwest at 7-10 knots with a light swell. System Design Simply defined, a system is an entity that exists to carry out some purpose.[2] A system is composed of humans, machine and other things that interact to accomplish a goal. Basic principles of systems design seek to reduce error by eliminating opportunities for operators to produce error within the system, by making errors visible and reversible and by mitigating error consequence. Every interaction between the operator and the machine (any type of physical object) within the system provides an opportunity for human error. For those operator-machine interfaces that are considered essential, it is imperative that the operator is able to control the machine. In order to do this, the user must know the state the machine is in and must be able to change that state or effect change. These two tasks are carried out by means of displays and controls, respectively.[3] Effective Communication Information transfer is a complex process and there are numerous opportunities for breakdown. A common problem is the failure to initiate communication. In many cases the needed information exists but is not made available to, or sought by, those who require it. Another common problem is incomplete or ambiguous communication. Additional problems could include failure to transmit information at the appropriate time or a misunderstanding of the information by the receiver.